A clinical study of vault hematomas after different types of ...

Research article
Int J Pharm Biomed Sci 2013, 4(3), 91-95
ISSN No: 0976-5263
Research Drops
PharmaInterScience Publishers
A clinical study of vault hematomas after different types of
hysterectomies
Hemant Deshpande*,
Mangal Puri,
Priyanka Dahiya
Department of Obstetrics & Gynaecology,
Padmashree Dr.D.Y.Patil Medical College,
Hospital and Research Centre,
Dr.D.Y.Patil University, Pimpri,
Pune-411018, India
*Correspondence:
Dr. Hemant Deshpande
Tel: +91 9422033660
E-mail: drhemantdeshpande @gmail.com
Background: Hysterectomy in the one operation for different indications.
Vault collection after hysterectomy is a known complication. To find out the
incidence of ultrasonologically detectable vault hematoma and related
postoperative morbidity is the aim of present observational study. Materials and
Methods: A group of 200 women, 100 of whom underwent abdominal (group
A) and 100 underwent vaginal hysterectomy (group B) was studied and evaluated
for incidence of ultrasonologically detectable postoperative vault hematoma
formation and its relation with postoperative morbidity. Results: Vault
hematoma is common after nondescent vaginal hysterectomies; use of catgut
sutures and with continuous locking sutures for vault closure increases granuloma
formation. Conclusion: Postoperative ultrasound need not be a routine
procedure, but should be done for NDVH and for patients with other risk factors.
Use of polyglycolic sutures reduces granuloma formation.
Key words: Vibroacoustic stimulation, Biophysical variables, high risk
pregnancy.
Received: 06 Dec 2012 / Revised: 10 Dec 2012 / Accepted: 11 Dec 2012 / Online publication: 09 Sep 2013
1. INTRODUCTION
Hysterectomy is the one operation performed for different
benign and malignant diseases of uterus. Vaginal route for
hysterectomy is preferred as it is safe and effective procedure
for benign non prolapsed uterus especially less than 12 weeks
size uterus [1]. “Every hysterectomy should be considered as
vaginal, unless there is a contraindication”[2]. Though this
should be accepted universally, place of abdominal and other
types of hysterectomies can’t be denied. We perform non
descent vaginal hysterectomy (NDVH) for indications, such
as dysfunctional uterine bleeding [3] and fibromyoma [4,5].
Vaginal route is associated with less risk of intra-operative as
well as post-operative haemorrhage [6], fewer needs of blood
transfusions [7], less operative time, least involvement of
peritoneal cavity, early oral diet permissibility, early
ambulation and quick convalescence [8] with less febrile
morbidity and shorter hospitalization. On the contrary Raj
Mohan [9] in his study has cited that vault hematoma is a
common finding in the first week after hysterectomy and has
no significant correlation with surgical technique or surgical
blood loss. Although large hematomas are associated with
febrile morbidity, most hematomas are small and self
resolving [10-12] magnitude of this with respect to
subsequent infection and other types of morbidity differ.
Complain of vaginal bleeding may last longer than expected
[13]. Postoperative vault hematoma increases postoperative
febrile morbidity due to infective pathology. Pelvic abscess,
vaginal bleeding and discharge, abdominal pain, frequency of
micturition, retention of urine, anaemia etc. are other causes
of morbidity. Postoperative ultrasound helps to diagnose
hematoma earlier for early intervention to prevent these
morbidities in patients with high risk factors.
The broad objective of the present study is to examine the
(i) incidence, causes and clinical picture in cases of
ultrasonologically detectable vault hematoma and vault
granuloma following different types of hysterectomies and
their indications (ii) association of risk factors, morbidity and
haemorrhage, with vault hematoma formation (iii)
association of suture material and vault suturing technique
with vault hematoma and vault granuloma formation”
2. MATERIALS AND METHODS
The study was started as a prospective-observational
study at Tertiary care centre and Teaching hospital for two
years, from Jan 2010 to Dec 2011. Study group was of 200
consecutive women who underwent abdominal and vaginal
hysterectomies. Patients were divided in two groups. Group
A-abdominal hysterectomy, 100 cases. Group B included
vaginal hysterectomies for 100 cases with or without pelvic
floor repair, non-descent vaginal hysterectomies (NDVH)
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Hemant Deshpande et al, Int J Pharm Biomed Sci 2013, 4(3), 91-95
92
Table 1
Indications for abdominal and vaginal hysterectomies
Abdominal hysterectomy
Vaginal hysterectomy
Indication No. of cases No. of hematoma case (%) Indication No. of cases No. of hematoma case (%)
Large multiple fibroids 10 2(20) UV prolapse 70 5(7.14)
Fibroids 15 1(6.67) Fibroid 10 2(20)
DUB 45 0(0) DUB 15 2(13.33)
PID 21 3(14.29) Adenomyosis 5 2(40)
Chronic cervicitis 5 1(20)
Endometriosis 4 0(0)
Total 100 7(7) 100 11(11)
and laparoscopically assisted vaginal hysterectomies
(LAVH), for different benign uterine diseases.
Ethical committee permission was obtained for the study.
All patients were clinically evaluated by detail history,
thorough clinical examination, and needful investigations
along with pre-operative ultrasound assessment.
Preoperative assessment was done for high risk factors like
hypertension, chronic intake of aspirin, ischemic heart
disease, anticoagulant therapy, diabetes mellitus and
coagulopathy for increased bleeding tendencies. After final
diagnosis and indication for hysterectomy, decision regarding
route of hysterectomy was decided, to group the patients.
Hysterectomies were performed by different experienced
gynaecologists. A single dose of intravenous antibiotic,
Injection Cefixime 1 gm was given one hour pre-operatively.
Suture material and suturing technique used for vault closure
was recorded. Amount of blood loss, units of blood
transfused and operative time were recorded for every
patient. Type of haemorrhage, if present, was recorded as per
type - primary, reactionary or secondary.
Postoperative morbidity was assessed by complains like
abdominal pain and distension, fever, weakness, bleeding and
foul smelling discharge per vaginum. Postoperative vitals
were noted twice a day in the form of pulse rate, temperature
and blood pressure. Daily abdominal examination was
performed for distension, tenderness, guarding and rigidity.
Inspection of vulva was done daily for presence of any
vaginal discharge. Per speculum examination under aseptic
precautions was performed for the patients complaining of
bleeding per vaginum.
Transabdominal and transvaginal ultrasound was
performed in each case on 3 rd , 7 th and postoperative days
and if required on subsequent follow up after 4 weeks.
The size of any vault collection (non peristaltic complex
echogenic mass) was noted and classified according to its
mean diameter, i.e. small = 5cm. Patients with a detected pelvic
hematoma were subjected to a follow up ultrasound scan
after 7 days and onwards. Patients with large hematoma were
subjected to the evacuation of hematoma, in a lithotomy
position, with all aseptic precautions under anaesthesia.
Procedure for draining hematoma was removal of central two
sutures of the vaginal vault and if needed digital exploration
and evacuation. Insertion of Penrose drain was considered if
required. Patients with small hematomas were treated
conservatively for spontaneous resolution and observed for
any complications. Medium sized hematomas were treated
with antifibrinolytic agents like tranaxemic acid with a dose
of 500mg eight hourly intravenously or orally. Injectable
antibiotics were added to prevent any superseded infection.
The results were subjected to Chi-square test and Proportion
test for significance.
3. RESULTS
Table 1 shows indications for abdominal and vaginal
hysterectomies. Commonest indication for hysterectomy in
group A was DUB, fibroid uterus and in group B was genital
prolapse.
Incidence of vault hematoma in our study was 11%
following vaginal hysterectomy (VH). Maximum i.e. 45 out
of 100 cases of abdominal hysterectomies were performed for
DUB, none of them developed vault hematoma. Incidence of
vault hematoma was 7% after abdominal hysterectomy and
it was more in patients who underwent total abdominal
hysterectomies (TAH) for large multiple fibroids. Tyrone
Carpenter reported in his study, in around 5% of patients,
vault haematoma occured following abdominal hysterectomy
[14]. Total laparoscopic hysterectomies (TLH) were
performed in 20 patients, out them, two performed for fibroid
and PID developed hematoma. Incidence of hematoma
formation was 7.14% in patients with VH for uterine or
uterovaginal prolapse.
Table 2
Incidence of Vault haematoma and granuloma in relation to type of VH
Type of surgery
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No. of
cases
Vault
hematoma
Vault
granuloma
Abdominal procedures TAH 80 05(6.25%) 13(16.25%)
TLH 20 02(10%) 02(10%)
Total 100 07(7%) 15(15%)
Vaginal procedures VH 20 02(10%) 02(10%)
VH with repair 50 03(6%) 01(10%)
LAVH 10 02(5%) 01(10%)
NDVH 20 04(20%) 01(10%)
Total 100 11(11%) 05(5%)

Hemant Deshpande et al, Int J Pharm Biomed Sci 2013, 4(3), 91-95
Table 2 depicts incidence of hematoma and granuloma
formation in relation to surgical procedures. Incidence of
vault granuloma formation in abdominal hysterectomy is
15%. In vaginal procedures it is much less i.e. 5%. 20%
patients who underwent NDVH developed hematoma.
Hematoma and granuloma formation is negligible after
surgeries done for uterovaginal prolapse. Incidence of
hematoma after LAVH is 5% in our study.
Sunanda Bharatnur [15] in her comparative study of
abdominal versus vaginal hysterectomy in nondescent
cases has mentioned that vaginal cuff cellulitis
and vault granuloma was 44% in vaginal hysterectomy and
24% in abdominal hysterectomy.
Table 3 shows correlation of high risk factors for bleeding
tendencies with vault hematoma formation. Incidence is 20%
in patients with hypertension and 15% in patients with
adhesions and 20% in diabetic patients. It is much less i.e.
1.92% in patients without risk factors.
Table 4 shows significant relation (P

Hemant Deshpande et al, Int J Pharm Biomed Sci 2013, 4(3), 91-95
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hematoma was 19.4%, 70% had small-sized hematoma and
30% had large-sized hematoma. In other studies, incidence of
postoperative hematoma was detected 25-98% [5,8]. The
incidence of vault hematoma was found 19.4% in present
study. In these patients, 40%(8/20) had fever while only
2.4%(2/83) of cases without vault hematoma suffered from
fever due to UTI. Study done by Cem Dane et al [17]
indicates out of all women having vault hematoma,
70%(14/20) had small-sized hematoma and 30% (6/20) had
large-sized hematoma. Fifty percent of patients (3/6) with
large-sized hematoma, as compared to only 35%(5/14) with
small-sized hematoma, suffered from febrile morbidity.
Large-sized hematomas drained by vaginally, while all smallsized
pelvic hematomas managed by watchful expectancy
successfully. The significant difference was found mean
hemoglobin drop and postoperative stay in the hematoma
group or without hematoma group, concluding the
importance of sonographic detection of vaginal vault fluid
collection after hysterectomy.
Table 8
Assessment of post-operative morbidity parameters in patients with vault
hematoma
Parameters
Vault hematoma
Present (n=18) Absent (182)
Febrile morbidity 5(27.77%) 1
Drop in hemoglobin 4(5%) 80
Blood transfusion 3(33.33%) 10
Hb drop in g/dL 2.78 averagely 1.24 averagely
Table 9
Relation between size of hematoma and post operative morbidity
Small Medium Large
Total no of patients 6 7 5
Febrile morbidity 0 3 2
Average Hb drop 1g% 3g% 4g%
Blood transfusion 0 2 1
Mean duration of hospital stay 10 days 14 days 20 days
Readmission 0 0 1
Table 10
Relation between suturing technique and vault hematoma
Suturing technique Total no of cases Hematoma cases (%)
Continuous 100 9(9)
Intermittent 50 1(2)
Continuous locking 50 8(16)
Total 200 18(9)
χ 2 =5.98, P

Hemant Deshpande et al, Int J Pharm Biomed Sci 2013, 4(3), 91-95
comparable with other studies showing 25% patients with
small hematoma and 50% patients with large hematoma had
developed postoperative drop in haemoglobin levels [21]. In
our study, 25% of patients with small sized hematoma had
negligible morbidity.
All patients undergoing AH or VH alone do not require
routine postoperative pelvic ultrasound scan [22]. But
patients who undergo NDVH, LAVH, patients with
adhesions, presence of risk factors and patients with intra &
post-operative haemorrhage should be preferred to be
followed by ultrasound scan. Early diagnosis of vault
hematoma and immediate treatment intervention can reduce
the postoperative morbidity. In this study we could identify a
population of women at increased risk of postoperative
morbidity due vault hematoma following hysterectomy.
5. CONCLUSIONS
Routine post operative USG of vaginal vault on day 5
should be done in all patients undergoing NDVH especially
in hypertensive’s and diabetics and in indications for large
fibroid, endometriosis and chronic PID. Small and medium
hematomas resolve by expectant management whereas large
infected hematomas need C/S of pus and drainage under
anaesthesia. The incidence of vault hematomas is more
following vaginal hysterectomies due to inadequate
hemostasis, infection, high incidence of reactionary
haemorrhage and eversion of edges of vagina during vault
closure. Incidence of granuloma formation can be lowered by
using polyglycolic acid suture material with interrupted
suturing technique for vault closure done by experienced
surgeon [22].
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